Outcomes and anticoagulation use for elderly patients that present with an acute hip fracture: multi-centre, retrospective analysis.

BACKGROUND: Hip fractures are a common problem and corrective surgery is recommended within 24 h. However, most peri-operative direct oral anticoagulant (DOAC) guidelines suggest a washout period of 48 h before major surgery. There are limited data on utility of drug levels. AIM: To investigate the effect of DOAC therapy on time to surgery and patient outcomes, and to explore the impact of different pre-operative protocols on surgical delay. METHODS: A multi-centre, retrospective analysis of all adult patients that presented with acute hip fracture at three tertiary hospitals in Perth, Western Australia, was performed. Data were collated from the West Australian hip fracture registry and electronic records. Time to theatre, DOAC levels, bleeding and transfusion rates were compared between sites. RESULTS: Of 1240 hip fracture patients, 146 (11.9%) were on anticoagulation, with more patients taking a DOAC than warfarin. The time to surgery was significantly longer for those on a DOAC compared with those on warfarin (P = 0.003). There was no difference in bleeding, transfusion requirement or 30-day mortality in patients taking a DOAC compared to those on warfarin. Fifty-eight (70.7%) patients had a DOAC level prior to surgery. Of 25 patients who had a level performed within 12 h of presentation, 13 (52%) had a result of ≤50 ng/mL. Outcomes were similar between sites. CONCLUSION: People on DOAC treatment had a significant delay before corrective surgery compared with those on warfarin. The frequent finding of early DOAC levels <50 ng/mL suggests this delay may be unnecessary in a significant proportion of patients.

A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments.

OBJECTIVE: To implement and evaluate a multimodal intervention to improve osteoporosis treatment in patients with a fragility fracture. DESIGN, SETTING AND PARTICIPANTS: Strategies to improve the management of patients discharged from an emergency department after presentation with fragility fracture were implemented prospectively in a large tertiary public hospital. Patients were surveyed by post to assess their awareness of osteoporosis and of the need for treatment. General practitioners and hospital clinicians completed an online questionnaire about their attitudes to osteoporosis and its management. A simplified consensus guideline was developed for local use. Our study was conducted between 1 October 2007 and 31 October 2008. MAIN OUTCOME MEASURES: Rates of referral of patients for osteoporosis review; rates of investigation and treatment. RESULTS: Although most GPs (259/306 [85%]) accepted that it was their responsibility to assess and treat their patients and inform them of their osteoporosis risk, only 35/87 patients (40%) indicated awareness of their risk. After implementation of our project, the rate of bone mineral densitometry investigations improved from 6/200 (3%) to 39/87 (45%) (P < 0.05). The number of patients receiving calcium and vitamin D supplementation increased from 24/200 (12%) (for both supplements) to 29/87 (33%) and 32/87 (37%), respectively (P < 0.05). Initiation of specific treatments increased from 12/200 (6%) to 26/87 (30%) (P < 0.05). Referral of eligible patients to the Fragile Bone Clinic for osteoporosis review improved from 20/500 (4%) to 51/194 (26%). After being contacted by a fracture liaison nurse, 84% of these patients presented for osteoporosis review in the clinic. CONCLUSIONS: A major key to improving osteoporosis management is to actively identify all patients at risk and proactively engage and encourage them to seek assessment and management. A multimodal strategy involving a dedicated fracture liaison nurse may offer the greatest potential for improving education and patient follow-up and treatment.

Vitamin D and muscle strength in patients with previous fractures.

AIM: To assess the vitamin D status and its association with objective left leg muscle strength measurements in patients with long-bone fracture discharged from a tertiary hospital in Western Australia. The secondary objective was to determine whether tests of balance and functional status are valid predictors of muscle strength and if they correlate with serum 25 hydroxyvitamin D (25OHD) levels. METHODS: This was a cross sectional study. Patients who had been discharged from a tertiary hospital following a low impact fracture over a 12-month period were invited to participate. Invitation was through a postal survey audit of osteoporosis risk and treatment and requesting participation in the study. Females over the age of 60 were included. Patients agreeing to participate were invited to attend a research clinic. Patients had demographic data, muscle strength, functional assessments, and biochemical parameters including serum 25OHD assessed. RESULTS: Of the 99 subjects who completed the study, the mean 25OHD level was 52.0 nmol/L. The main univariate associations with 25OHD were cognitive function, functional indices, sun exposure, albumin, and parathyroid hormone (PTH). In a multivariate model,the strongest and most significant association was between muscle strength and 25OHD levels (r=0.489, p<0.001). Muscle strength was most strongly associated with 25OHD levels >50 nmol/L (r=0.51, p<0.001). CONCLUSION: This study demonstrates a significant association between 25OHD levels and left leg muscle strength. This independent association supports the hypothesis that 25OHD deficiency may be responsible for poor muscle strength.